Ligament of Marshall

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A Moment in History

Jean George Bachmann
(1877 – 1959)

French physician–physiologist whose experimental work in the early twentieth century provided the first clear functional description of a preferential interatrial conduction pathway. This structure, eponymically named “Bachmann’s bundle”, plays a central role in normal atrial activation and in the pathophysiology of interatrial block and atrial arrhythmias.

As a young man, Bachmann served as a merchant sailor, crossing the Atlantic multiple times. He emigrated to the United States in 1902 and earned his medical degree at the top of his class from Jefferson Medical College in Philadelphia in 1907. He stayed at this Medical College as a demonstrator and physiologist. In 1910, he joined Emory University in Atlanta. Between 1917 -1918 he served as a medical officer in the US Army. He retired from Emory in 1947 and continued his private medical practice until his death in 1959.

On the personal side, Bachmann was a man of many talents: a polyglot, he was fluent in German, French, Spanish and English. He was a chef in his own right and occasionally worked as a chef in international hotels. In fact, he paid his tuition at Jefferson Medical College, working both as a chef and as a language tutor.

The intrinsic cardiac conduction system was a major focus of cardiovascular research in the late nineteenth and early twentieth centuries. The atrioventricular (AV) node was discovered and described by Sunao Tawara and Karl Albert Aschoff in 1906, and the sinoatrial node by Arthur Keith and Martin Flack in 1907.

While the connections that distribute the electrical impulse from the AV node to the ventricles were known through the works of Wilhelm His Jr, in 1893 and Jan Evangelista Purkinje in 1839, the mechanism by which electrical impulses spread between the atria remained uncertain.

In 1916 Bachmann published a paper titled “The Inter-Auricular Time Interval” in the American Journal of Physiology. Bachmann measured activation times between the right and left atria and demonstrated that interruption of a distinct anterior interatrial muscular band resulted in delayed left atrial activation. He concluded that this band constituted the principal route for rapid interatrial conduction.

Subsequent anatomical and electrophysiological studies confirmed the importance of the structure described by Bachmann, which came to bear his name. Bachmann’s bundle is now recognized as a key determinant of atrial activation patterns, and its dysfunction is associated with interatrial block, atrial fibrillation, and abnormal P-wave morphology. His work remains foundational in both basic cardiac anatomy and clinical electrophysiology.

Sources and references
1. Bachmann G. “The inter-auricular time interval”. Am J Physiol. 1916;41:309–320.
2. Hurst JW. “Profiles in Cardiology: Jean George Bachmann (1877–1959)”. Clin Cardiol. 1987;10:185–187.
3. Lemery R, Guiraudon G, Veinot JP. “Anatomic description of Bachmann’s bundle and its relation to the atrial septum”. Am J Cardiol. 2003;91:148–152.
4. "Remembering the canonical discoverers of the core components of the mammalian cardiac conduction system: Keith and Flack, Aschoff and Tawara, His, and Purkinje" Icilio Cavero and Henry Holzgrefe Advances in Physiology Education 2022 46:4, 549-579.
5. Knol WG, de Vos CB, Crijns HJGM, et al. “The Bachmann bundle and interatrial conduction” Heart Rhythm. 2019;16:127–133.
6. “Iatrogenic biatrial flutter. The role of the Bachmann’s bundle” Constán E.; García F., Linde, A.. Complejo Hospitalario de Jaén, Jaén. Spain
7. Keith A, Flack M. The form and nature of the muscular connections between the primary divisions of the vertebrate heart. J Anat Physiol 41: 172–189, 1907.

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Details: Written by: Efrain A. Miranda, Ph.D.; Published: October 22, 2024; Hits: 1621

John Marshall (1818 – 1891)

The ligament of Marshall (LOM)is the embryological remnant of the sinus venosus and left cardinal vein. It contains fat, fibrocellular tissues, blood vessels, muscle bundles (bundles of Marshall), autonomic nerve fibers, and some ganglia corresponding to the ganglionated plexuses (plexi) of the heart.

It was first described by John Marshall (1818-1891) in an 1850 paper titled “On the Development of the Great Anterior Veins Man and Mammalia; including an Account of certain remnants of Fœtal Structure found in the Adult, a Comparative View of these Great Veins the different and an Analysis of their occasional peculiarities in the Human Subject”. In this paper, Marshall makes a detailed embryological description of the structures that derive from the left cardinal vein in the human and adds comparative anatomy with other mammalian species.

The left cardinal vein, which originally enters the left side of the sinus venosus, regresses and modifies leaving the following structures in the adult: From superior to inferior they are the brachiocephalic vein, the obliterated duct of Cuvier, the oblique vein of the left ventricle, and the coronary sinus.

The embryological remnant of the left cardinal vein closes and forms a fibrous cord known as the “duct of Cuvier” (named a after French anatomist and naturalist, Baron de la Cuvier (1769 – 1832)). As this fibrous cord crosses the gap between the left pulmonary vein and the left superior pulmonary vein, the visceral pericardium creates a fold over it; that fold is the ligament of Marshall.

In his paper John Marshall calls it the “vestigial fold of the pericardium”. He describes in this fold “a duplicature of the serous layer of the pericardium, including cellular and fatty tissue, the vestigial fold contains some fibrous bands, small blood-vessels and nervous filaments” …” in the interval between the pulmonary artery and vein”.

The image shows the ligament of Marshall (yellow arrow), the left pulmonary artery (LPA), and the left superior pulmonary vein (LSPV). Click on the image for a larger depiction.

Marshall continues his description as the LOM descends toward the heart and states that there is a portion of the left cardinal vein that is total obliterated and sometimes “wanting”. This is the obliterated portion of the duct of Cuvier, which he does not specifically describes in the LOM. In some cases, Marshall says that the duct is absent and replaced by some whitish fibrous streaks crossing the base of the left pulmonary veins. Today we call this the “obliterated portion of the vein of Marshall”.

He then continues describing a small vein that continues towards and opens in the superior aspect of the coronary sinus. This is the patent portion of the duct of Cuvier, and he calls this structure the “small oblique auricular vein”. Today we call this the “oblique vein of the left atrium” or eponymically, the “vein of Marshall”. The coronary sinus is the end portion of the left cardinal vein.

Contemporary studies on the structure of the LOM have described autonomic nerve fibers and aggregations of neuronal bodies (ganglia) on and around the LOM. Also, cardiac musculature extending from the left atrium, and the coronary sinus over the root of the vein of Marshall have been described (bundles of Marshall).

In some cases, the left cardinal vein does not regress and presents in the adult as a “persistent left superior vena cava”. In this case there is no obliterated duct of Cuvier, the oblique vein of the left atrium and coronary sinus are enlarged, and the venous blood from the head and the left upper extremity drains through the coronary sinus into the right atrium. The following image shows a persistent left superior vena cava (yellow arrow), the left atrial appendage (LAA), the left pulmonary artery (LPA), and the left superior pulmonary vein (LSPV). Click on the image for a larger depiction.

Because of the autonomic nerve fibers and ganglia involved, the LOM (and coronary sinus) have been described as being one of the potential foci for atrial fibrillation (AFib) and has become a target for ablation in AFib surgical procedures.

Personal note: My personal thanks to my good friend and contributor to "Medical Terminology Daily", Dr. Randall K. Wolf for the surgical images.

Sources:
1. “On the Development of the Great Anterior Veins Man and Mammalia; including an Account of certain remnants of Fœtal Structure found Adult, a Comparative View of these Great Veins the different and an Analysis of their occasional peculiarities in the Human Subject” Marshall, J. 1850 Phil Trans R Soc 140:133 – 170
2. “The ligament of Marshall: a structural analysis in human hearts with implications for atrial arrhythmias” Kim, D, Lai, A, Hwang, C. et al. JACC. 2000 Oct, 36 (4) 1324–1327.
3. “Myocardium of the Superior Vena Cava, Coronary Sinus, Vein of Marshall, and the Pulmonary Vein Ostia: Gross Anatomic Studies in 620 Hearts” DeSimone CV, Noheria A, Lachman N, Edwards WD, et al. J Cardiovasc Electrophysiol. 2012 Dec; 23(12)
4. “Correlative Anatomy for the Electrophysiologist: Ablation for Atrial Fibrillation. Part I: Pulmonary Vein Ostia, Superior Vena Cava, Vein of Marshall” Macedo PG, Kapa S, Mears JA, Fratianni A, Asirvatham SJ. J Cardiovasc Electrophysiol. 2010 Jun 1;21(6):721-30.
5. “"Human Embryology" WLJ Larsen 1993 Churchill Livingstone
6. “Langman's Medical Embryology" Sadler, T.W. 7ed. Baltimore: Williams & Wilkins, 1995.
7. "Vascular Surgery: A Comprehensive Review" Moore, Wesley S. USA: W.B. Saunders, 1998.
8. Portrait of J. Marshall by Alphonse Legros, Courtesy of Wikipedia. Public Domain.

Ligament of Marshall

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